Acne Vulgaris

What is Acne Vulgaris?

This very common skin inflammation affects chiefly adolescents of both sexes. Indeed, it is almost part of “growing up,” and often commences soon after the hormonal changes of puberty. It is usually at maximum intensity in the teen years, and frequently persists into the 20s and occasionally beyond. Often there is a family history of acne.

The tiny sebaceous glands in the skin do not function during childhood. But later, under hormonal stimulation, they commence to produce sebum, a whitish fluid discharged to the skin surface to spread evenly over it throughout life.

Sebaceous production frequently gets out of hand with a heaping up of sebum at the skin surface. A Whitehead is formed. The material oxidises and turns black and a blackhead or comedone occurs.

Often these discharge simply onto the skin (with a little pressure, or spontaneously). But some remain “closed” and, indeed, as further sebum is added from beneath, increase in size, creating a pustule. If this increases in size before discharge, a large, often painful, cyst is formed (see Sebaceous Cysts). This may penetrate into the deeper tissues of the skin.

Often the walls of the cyst break down the sebaceous of skin overproduce, causing small pustules whiteheads and local inflammation internally, and the highly irritating contents invade surrounding structures. This increases the irritation and discomfort.

It is easy for germs to invade, and uncomfortable and very tender swellings very much like boils occur. A major problem with acne is the tendency for the pustules and cysts to empty out, leaving unattractive scars and depressions. Acne usually occurs on the face, but it may extend to the neck, shoulders and back as well.

A germ called the Corynebacterium is often present in acne lesions. However, this is not contagious, and is not harmful. Doctors talk about acne in various grades according to its severity.

Grade I is mainly on the face and consists of comedones and an occasional small pustule. Grade II is characterised by an increase in the number of pustules, but they are chiefly on the face region. Grade III is composed chiefly of many small pustules, which have spread from the face to the shoulders, back and chest. Grade IV is a very advanced state that is even more extensive, and many penetrate down to the waist. Large cysts and painful swellings are common. This is commonly called Acne conglobata. Acne sometimes occurs suddenly in persons living in tropical climates.

Acne Vulgaris Treatment

Many treatments have been advocated over the years, which in itself is testimony to the fact that no universally satisfactory routine exists at present. However, simple home routines are worth trying before recourse to a doctor for professional advice. It must be remembered that the course of acne normally waxes and wanes so that an apparent improvement with a certain remedy does not necessarily testify to its efficacy in the long-term.

Girls may notice pimples are much worse in the week just prior to a menstrual period. Progesterone, the hormone being formed in the body, is often present at high levels and seems to aggravate it all. It is unfortunate. I might add that the less you think about your pimples, the better it is. Often problems from pimples are more in the mind than on the face. Flour and sugar-containing products and fatty foods rarely help, and could aggravate what may be a trying and persisting condition.

The simplest starting point is to wash the face, and all affected parts (it may extend to the shoulders, chest and back) with soap and hot water. Many blackheads can then be gently squeezed or eliminated with a “comedone extractor” (available from the pharmacist). Some say that squeezing is a bad idea, for it may spread infection. But when the face is hot they will often pop readily, eliminating the fatty material.

After this a lotion or cream may be applied. There are many different varieties, some containing sulphur and smelling vile. Salicylic acid and tar products, and sometimes corticosteroids are useful. A satisfactory application is benzoyl peroxide gel 5 per cent (Panoxyl Acne Gel).

This is rubbed in once or twice a day (probably best at bedtime) and is supposed to take oxygen to the cells below the surface and help clear the condition. Another product claimed to help is tretinoin, either in the form of a liquid or gel (Retin-A). This is a derivative of vitamin A, long believed to help acne, and the local application can often assist. Follow the directions on the packing slip, and keep out of bright sunshine, otherwise the skin becomes very red.

If acne is a persisting problem at puberty; it may need treatment by a skin specialist. If simple local measures are ineffective, it’s worth seeking medical advice from the doctor. Often the tetracycline antibiotics are used for adults. This may continue for many months or a year or even more. This seems to reduce sebum formation. The capsules must not be taken with food. Take three times daily between meals. A zinc tablet taken daily sometimes helps persisting cases. Occasionally a form of the oral contraceptive hormonal tablet is also effective.

Roaccutane is prescribed by skin specialists for severe cystic acne, but there are special precautions.

Here are some of the suggestions for a start:

  • Simple cleanliness. Wash the face and all affected parts with soap and hot water at least twice a day. Wash thoroughly, especially in the areas where grease tends to accumulate (in crevices such as thenasal folds). Ordinary soap is quite adequate. Medicated soaps containing hexachlorophene preparations may worsen the condition. Avoid greasy cleansing creams and other cosmetics.
  • Shampoo the scalp once or twice a week, especially if there is any sign of dandruff which indicates overactivity of the sebaceous glands. Selenium sulphide or a similar preparation is recommended; otherwise use an ordinary detergent based shampoo.
  • Gently squeeze out any blackheads. Some prefer a comedone extractor, a metal object with a hole in the centre. When the extractor is placed over the blackhead and pressure applied, the blackhead pops out into the hole in the instrument and leaves the skin surface if the blackhead is resistant to pressure, hot applications for a few minutes may reduce the resistance. Do not exert undue pressure.
  • Dab dry with a soft towel then apply a lotion. This is aimed at increasing the blood supply to the skin, and helping the upper skin layers to peel off gradually and so remove the acne lesions. Simple hot water or Epsom salt compresses are often used, or a sulphur-zinc lotion may be applied. Lots of different prescriptions are available.
  • This one has been used for many years, and often helps:
    • Sulphur (Ppt.)
    • Zinc sulphate
    • Sodium borate
    • Zinc oxide
    • Acetone: .30 parts
    • Camphor water, equal parts, made up to Rose water 120 parts

    This lotion is applied each night after the cleansing routine.

  • Many commercial preparations are readily available, and most of these are satisfactory for this same purpose. These include Eskamel and Acnederm. These may be applied at bedtime and removed in the morning.
  • Vitamin A tablets (50,000 in with each meal). This treatment is still claimed by some physicians to be of value. Others doubt it. It may be continued for three months.
  • Diet. A sensible, well-balanced diet is recommended. However, avoidance of chocolate in all forms seems to help a significant number of acne sufferers. (This includes chocolates as such, chocolate containing beverages such as cocoa and similar drinks and milkshakes, and cola drinks.) It’s wise to go lightly on excess carbohydrate foods, nuts, fried and fatty foods and alcoholic beverages. Some doctors suggest removing a certain set of foods from the diet for three weeks and awaiting results, then reintroducing them one by one to see if in fact they play a significant role in producing the disorder. (If so, it will be indicated by an upsurge of pimples when the offending items are reintroduced into the diet.) General measures. It is worthwhile correcting any basic physical derangements.
  • Correct indigestion; treat any underlying infection, malnutrition, anaemia or constipation. Emotional upsets should be avoided, and tensions and anxieties kept to a minimum.

If these simple measures fail to produce an improvement, it’s time to visit your family physician. There are several other courses of action available. They include the following:

  • Antibiotics. The broad-spectrum antibiotics (such as the tetracyclines and erythromycin) exert a beneficial effect on the lesions of acne for reasons not well understood. Often the severe forms of acne respond best. Dose given is variable but often a larger dose commences the routine, e.g. Tetracycline 1 or 2 x 250 mg capsules are given three times a day. It is essential that these are not taken with food, which destroys their action. Therefore they should be taken midmorning, midafternoon and at bedtime. Sometimes dose is increased from one, to two, and later to three capsules three times a day. It may be necessary to continue with the routine for six, nine, twelve months or even longer during the turbulent teen years. Results are almost always satisfactory. Side effects are rare.

    If one antibiotic does not produce the desired results, a switch to another type often will. Clindamycin is excellent, but may cause diarrhoea in some.

  • Oral contraceptives. The pill, which is merely the combination of two normally occurring hormones, often has a beneficial effect on acne, which in women is often worse just prior to menstruation. A pill low in progesterone is usually of greatest advantage. Other doctors sometimes find that low doses of stilboestrol for 10 days following a woman’s menstrual period give good results.
  • Injections of fluorinated steroids into very severe lesions are sometimes carried out by the doctor.
  • Oxygen-producing gels and lotions to be applied at night are often successful (e.g. Panoxyl Acne Gel or Lotion).
  • Retin-A lotion (a vitamin A preparation) applied to the affected spots is often successful. The directions must be carefully followed.
  • Local applications containing steroids and antibiotics in an emulsion base are often satisfactory in addition to these measures.
  • Often simple exposure to sunlight gives beneficial results. Ultraviolet light can also assist. In severe cases, X-radiation by a skin specialist can give excellent results when all other methods fail, but this is now rarely used.

Acne Vulgaris Scarring

A major problem with acne is the multiple scarring that causes embarrassment. Effective and vigorous treatment during the course of the disease, however, will often obviate major scarring.

  • Dermabrasion (the removal of the scar with a rapidly turning wire brush) often gave excellent results. However, as many patients were dissatisfied with the results because excessive pigmentation sometimes occurred at the margins, this has now fallen from favour. Some specialists apply carbon dioxide “slush” at fortnightly intervals. Others recommend the use of abrasive substances that are applied manually then washed off (e.g. Brasivol). Deep scars may require the attention of a plastic surgeon. However, the scar is often more in the mind of the patient than on the face, and careful thought should be given before such heroic ventures are embarked upon. They are expensive, too, despite national insurance schemes. Cosmetic surgery was never cheap.
  • Injection therapy. The use of collagen given by injection under the scar will often eliminate the depression. It is expensive therapy, usually carried out by the plastic surgeon or specially trained skin specialist. It is not a “forever cure,” but lasts anywhere from one to three years, when it may have to be repeated for continuity of appearance.
  • Severe pustular acne. The oral use of a powerful drug called isotretinoin (Roaccutance is the commercial name) may often have a dramatic beneficial effect in clearing severe acne with cysts and pus-affected, fluid-filled areas under the skin and which have not responded to any other treatment. It must be given under the supervision of a skin specialist. It is essential the person is not pregnant, for it is well-known to cause birth defects.

Otherwise, results are often dramatic. It is expensive, but this is often a small price to pay for a brand-new appearance.

Skin Disorders Related to Acne Vulgaris

  • Rosacea. This is a permanent flushing in the region of the forehead, nose and cheeks, and is common in people 20 years and over. Pustules may form and the skin over the nose often thickens, and minute superficial veins appear. Refer to section on Rosacea.